Risk factors for hepatocellular carcinoma: an umbrella review of systematic review and meta-analysis

BACKGROUND

Numerous meta-analyses have identified various risk factors for hepatocellular carcinoma (HCC), prompting a comprehensive study to synthesize evidence quality and strength.

METHODS

This umbrella review of meta-analyses was conducted throughout PubMed, EMBASE, Web of Science, and Cochrane Database of Systematic Reviews. Evidence strength was evaluated according to the evidence categories criteria.

RESULTS

We identified 101 risk factors throughout 175 meta-analyses. 31 risk factors were classified as evidence levels of class I, II, or III. HBV and HCV infections increase HCC risk by 12.5-fold and 11.2-fold, respectively. These risks are moderated by antiviral treatments and virological responses but are exacerbated by higher HBsAg levels, anti-HBc positivity, and co-infection. Smoking, obesity, non-alcoholic fatty liver disease, diabetes, low platelet, elevated liver enzymes and liver fluke infection increase HCC risk, while coffee consumption, a healthy diet, and bariatric surgery lower it. Medications like metformin, glucagon-like peptide-1 receptor agonists (GLP-1 RAs), aspirin, statins, and selective serotonin reuptake inhibitors reduce HCC risk, while acid suppressive agents, particularly proton pump inhibitors, elevate it. Blood type O reduces the risk of HCC, while male gender and older age increase the risk.

CONCLUSIONS

HBV and HCV are major HCC risk factors, with risk mitigation through antiviral treatments. Lifestyle habits such as smoking and alcohol use significantly increase HCC risk, highlighting the importance of cessation. Certain drugs like aspirin, statins, GLP-1 RAs, and metformin may reduce HCC occurrence, but further research is needed to confirm these effects.

An overview of downhill esophageal varices: a challenge for medical practice

OBJECTIVES

Unlike the commonly seen uphill esophageal varices in clinical practice, downhill esophageal varices are caused by obstruction of the superior vena cava and azygous venous system. The predominant causes of downhill esophageal varices are hemodialysis in end-stage renal disease patients and mediastinal malignancies. The cornerstone of the treatment for downhill esophageal varices is to address the underlying primary causes. Without this, patients may suffer from recurrent bleeding, and the bleeding can be fatal.

METHODS

This review is primarily summarized through previous case reports. Meanwhile, it emphasizes the significance of case reports.

RESULTS

Clinicians should be conscious that esophageal varices are not necessarily caused by liver cirrhosis or non-cirrhotic portal hypertension.

CONCLUSIONS

Specifically, when varices are only observed in the upper and middle esophagus, and the patient presents with evidence of superior vena cava obstruction, clinicians should be particularly vigilant for downhill esophageal varices. Moreover, a thorough investigation and definitive treatment of the underlying primary causes should be implemented.

The interplay between gut microbiome, epigenetics, and substance use disorders: from molecular to clinical perspectives

Substance use disorders (SUDs) involve a complex series of central and peripheral pathologies, leading to impairments in cognitive, behavioral, and physiological processes. Emerging evidence indicates a more significant role for the microbiome-gut-brain axis (MGBA) in SUDs than previously recognized. The MGBA is interconnected with various body systems by producing numerous metabolites, most importantly short-chain fatty acids (SCFAs), cytokines, and neurotransmitters. These mediators influence the human body's epigenome and transcriptome. While numerous epigenetic alterations in different brain regions have been reported in SUD models, the intricate relationship between SUDs and the MGBA suggests that the gut microbiome may partially contribute to the underlying mechanisms of SUDs. Promising results have been observed with gut microbiome-directed interventions in patients with SUDs, including prebiotics, probiotics, antibiotics, and fecal microbiota transplantation. Nonetheless, the long-term epigenetic effects of these interventions remain unexplored. Moreover, various confounding factors and study limitations have hindered the identification of molecular mechanisms and clinical applications of gut microbiome interventions in SUDs. In the present review, we will (i) provide a comprehensive discussion on how the gut microbiome influences SUDs, with an emphasis on epigenetic alterations; (ii) discuss the current evidence on the bidirectional relationship of gut microbiome and SUDs, highlighting potential targets for intervention; and (iii) review recent advances in gut microbiome-directed therapies, along with their limitations and future directions.

Intra- and Interobserver Variability of Acute Food-Induced Reactions During Confocal Laser Endomicroscopy: An International Multicenter Validation Study

BACKGROUND AND STUDY AIMS

Probe-based confocal laser endomicroscopy (pCLE) enables real-time microscopic visualization of the duodenal mucosa and has shown acute food-triggered disruption of the duodenal epithelial barrier of patients with irritable bowel syndrome (IBS). The interpretation of the recordings is subjective, with unknown agreement rates. The aim of this study was to investigate the intra- and interobserver variability of this technique.

PATIENTS AND METHODS

An international multicenter study was performed, including pCLE recordings from three centers. Recordings were randomized and re-evaluated by five blinded experienced assessors. Low-quality recordings were excluded. The mucosa was considered altered if both fluorescein leakage and luminal particles were observed. Agreement was quantified using Fleiss' and Cohen's kappa (κ). Reference videos (i.e., videos with 100% agreement) were used to assess the optimal characteristics of videos needed to make a judgment based on the optimal receiver operating characteristic curve cutoff.

RESULTS

Of the 119 individual recordings, 87 could be used for analyses (total of 86,408 frames). Intraindividual agreement rate was 80%-100%, whereas the interindividual agreement rate was 85% (κ = 0.68). The agreement rate with the endoscopist ranged 54%-95% (κ = 0.15-0.89). The optimal cutoff to distinguish altered from unaltered was by observing alterations in ≥ 2 out of 6 mucosal spots (100% sensitivity and specificity).

CONCLUSION

Our study showed a substantial to perfect intraobserver agreement and a substantial interobserver agreement for the judgment of acute food-triggered disruption of the duodenal epithelial barrier by pCLE, confirming that this real-time readout is reliable and reproducible.

Prevalence and risk of progression of pancreatic cystic lesions in immunosuppressed patients: A systematic review and meta-analysis

BACKGROUND

Pancreatic cystic lesions are common in patients eligible for solid organ transplantation. It has been shown that the need for immunosuppression after organ transplantation increases the rate of malignancies in organ recipients. However, the impact of immunosuppression on pancreatic cystic lesions is yet unknown.

AIM

To evaluate the prevalence of pancreatic cystic lesions and the risk of cyst progression in immunosuppressed patients.

METHODS

A systematic literature search was performed in relevant databases. Studies reporting either on the prevalence and/or the incidence of pancreatic cyst progression compared to a control group were implemented in the first systematic review and meta-analysis on this topic.

RESULTS

The prevalence of pancreatic cystic lesions was comparable with 7% (95%CI: 5%-11%) in the immunosuppressed cohort and 9% (95%CI: 5%-16%) in the control cohort. The mean cyst size increase in the immunosuppression group was 3.2 mm (range 1.0-5.2mm) compared to 3.5 mm (1.0-6.9) in the control group (standardized mean difference 0.0 mm, 95%CI: -0.3-0.2 mm, P = 0.72). There was also no significant increase in the development of resection criteria or worrisome features under immunosuppression either [relative risk 1.1 (fixed effect model), 1.2 (random effects model), P = 0.61].

CONCLUSION

Immunosuppression does not increase the prevalence of pancreatic cystic lesions, nor does it increase the risk of cyst progression in terms of cyst size and development of resection criteria. Therefore, pancreatic cystic lesions in transplant candidates should not be a contraindication for solid organ transplantation.

The effect of flavan-3-ols on ovariectomy-induced bone loss in mice and the potential mechanisms

Flavan-3-ols (FLOs) have been reported to confer various health benefits, the majority of which reaching the colon for fermentation by gut microbiota. This study sought to examine the effects of FLOs on bone health and to evaluate the influence of gut microbiota on these effects. Using an ovariectomy-induced bone loss model in mice, the animals were administered either a low or high dose of FLOs, or a combination of FLOs with an antibiotic cocktail (Abs+FLOs). Compared to the control group, serum markers of bone formation, as well as bone quality as determined by micro-CT, were elevated in the groups supplemented with FLOs, particularly when combined with Abs. Furthermore, both FLOs and Abs+FLOs interventions significantly improved the levels of estrogen. However, no additional influence of FLOs on these markers was detected compared to the group supplemented with Abs alone. Analysis of 16S rRNA sequencing data revealed that the abundance of certain operational taxonomic units, such as s__unclassified_Clostridia_UCG_014, s__unclassified_Ruminococcus, and s__unclassified_Lachnospiraceae, was significantly reduced in osteoporotic mice but effectively reversed following the administration of FLOs. Transcriptomic analysis coupled with KEGG enrichment analysis indicated that Adrb3, Gdf10 (BMP3), Fosb, and Cxcl2, along with the PPARα/PGC-1/UCP1 signaling pathway, may potentially mediate the regulation of bone metabolism by flavanols. Collectively, the study uncovers the osteoprotective properties of flavan-3-ols, indicating that these effects may depend on the presence of gut microbiota.

Artificial intelligence in gastrointestinal surgery: A minireview of predictive models and clinical applications

BACKGROUND

Artificial intelligence (AI) is playing an increasingly significant role in predicting outcomes of gastrointestinal (GI) surgeries, improving preoperative risk assessment and post-surgical decision-making. AI models, particularly those based on machine learning, have demonstrated potential in predicting surgical complications and recovery trajectories.

AIM

To evaluate the role of AI in predicting outcomes for GI surgeries, focusing on its efficacy in enhancing surgical planning, predicting complications, and optimizing post-operative care.

METHODS

A systematic review of studies published up to March 2025 was conducted across databases such as PubMed, Scopus, and Web of Science. Studies were included if they utilized AI models for predicting surgical outcomes, including morbidity, mortality, and recovery. Data were extracted on the AI techniques, performance metrics, and clinical applicability.

RESULTS

Machine learning models demonstrated significantly better performance than logistic regression models, with an area under the curve difference of 0.07 (95%CI: 0.04–0.09; P < 0.001). Models focusing on variables such as patient demographics, nutritional status, and surgical specifics have shown improved accuracy. AI’s ability to integrate multifaceted data sources, such as imaging and genomics, contributes to its superior predictive power. AI has improved the early detection of gastric cancer, achieving 95% sensitivity in real-world settings.

CONCLUSION

AI has the potential to transform GI surgical practices by offering more accurate and personalized predictions of surgical outcomes. However, challenges related to data quality, model transparency, and clinical integration remain.

Current status of artificial intelligence colonoscopy on improving adenoma detection rate based on systematic review of multiple metanalysis

BACKGROUND

Colorectal cancer (CRC) can be prevented by screening and early detection. Colonoscopy is used for screening, and adenoma detection rate (ADR) is used as a key quality indicator of sufficient colonoscopy. However, ADR can vary significantly among endoscopists, leading to missed polyps or cancer. Artificial intelligence (AI) has shown promise in improving ADR by assisting in real-time polyp identification or diagnosis. While multiple randomized controlled trials (RCTs) and metanalyses highlight the benefits of AI in increasing detection rates and reducing missed polyps, concerns remain about its real-world applicability, impact on procedure time, and cost-effectiveness.

AIM

To explore the current status of AI assistance colonoscopy in adenoma detection and improving quality of colonoscopy.

METHODS

This systematic review followed PRISMA guidelines, both PubMed and Web of Science databases were used for articles search. Metanalyses and systematic reviews that assessed AI's role during colonoscopy. English article only published between January 2000 and January 2025 were included. Articles related to non-adenoma indications were excluded. Data extraction was independently performed by two researchers for accuracy and consistency.

RESULTS

22 articles met the inclusion criteria, with significant heterogeneity (I² = 28%-91%) observed in multiple studies. The number of studies per metanalysis ranged from 5 to 33, with higher heterogeneity in analyses involving more than 18 RCTs. AI demonstrated improvement in ADR, with an approximate 20% increase across multiple studies. However, its effectiveness in detecting flat or serrated adenomas remains unproven. Endoscopists with low ADR benefit more from AI-colonoscopies, while expert endoscopists outperformed AI in ADR, adenoma miss rate, and the identification of advanced lesions. No significant change in withdrawal time was observed when comparing AI-assisted colonoscopy to conventional endoscopy.

CONCLUSION

While AI-assisted colonoscopy has been shown to improve procedural quality, particularly for junior endoscopists and those with lower ADR, its performance decreases when compared to expert endoscopists in real-time clinical practice. This is especially evident in non-randomized studies, where AI demonstrates limited real-world benefits despite its benefit in controlled settings. Furthermore, no meta-analyses have specifically examined AI's impact on the learning experience of fellows and residents. Some experts caution that reliance on AI may prevent trainees from developing essential observational skills, potentially leading to less thorough examinations. Further research is needed to determine the actual benefits of AI-colonoscopy, particularly its role in cancer prevention. As technology advances, improved outcomes are expected, especially in detecting small, flat, and lesions at difficult anatomical locations.

Interobserver agreement in dysplasia grading of intraductal papillary mucinous neoplasms: performance of Kyoto guidelines and optimization of endomicroscopy biomarkers through pathology reclassification

BACKGROUND AND AIMS

Interobserver agreement (IOA) among pancreaticobiliary (PB) pathologists in evaluating high-grade dysplasia and/or invasive carcinoma (HGD-IC) of intraductal papillary mucinous neoplasms (IPMNs) remains understudied. EUS-guided needle-based confocal endomicroscopy (nCLE) can evaluate papillary architecture in branch duct IPMNs. We assessed IOA among PB pathologists in classifying dysplasia in resected IPMNs and compared the performance of the Kyoto guidelines' high-risk stigmata (HRS) and presurgical EUS-nCLE against reclassified pathology.

METHODS

Participants in prospective clinical trials (2015-2023) with resected IPMNs were included. Blinded PB pathologists independently reviewed histopathology, achieving a consensus diagnosis. The accuracies of cyst fluid next-generation sequencing analysis, EUS-nCLE, and Kyoto HRS in predicting HGD-IC were compared with the reclassified pathology.

RESULTS

Among 64 participants, 25 (39%) exhibited HGD-IC (17 HGD, 8 invasive carcinoma). Disagreements occurred in 14% of cases with substantial IOA (κ = 0.70; 95% confidence interval, 0.53-0.88) between 2 PB pathologists for differentiating HGD-IC versus low-grade dysplasia (LGD). To detect HGD-IC, the sensitivity, specificity, and accuracy of Kyoto HRS and EUS-nCLE were 52%, 95%, 78% and 68%, 87%, 80%, respectively. Integrating nCLE with Kyoto HRS improved sensitivity to 80%, with specificity and accuracy at 82% and 81%, respectively. The sensitivity, specificity, and accuracy of next-generation sequencing (n = 47) to detect HGD-IC were 6.3%, 100%, and 68%, respectively. A unique subset of IPMNs were identified in all (n = 8, P = .01) cases where presurgical EUS-nCLE underestimated dysplasia revealing a distinct micropapillary architecture on postsurgical histopathology.

CONCLUSIONS

Despite substantial IOA among experienced PB pathologists, a second pathologist's review may be warranted for dysplasia classification in IPMNs under certain circumstances. Incorporating an imaging biomarker such as EUS-nCLE with Kyoto HRS improves sensitivity for HGD-IC without sacrificing accuracy.

The Role and Appropriate Selection of Guidewires in Biliopancreatic Endoscopy

Guidewires are indispensable tools in biliopancreatic endoscopy, playing a critical role in facilitating access and enabling the advancement of various devices during interventions such as Endoscopic Retrograde Cholangiopancreatography (ERCP) and Endoscopic Ultrasound (EUS)-guided procedures. These devices are primarily used to achieve and maintain access to lumens, ensuring the success of complex therapeutic maneuvers. Guidewires vary widely in terms of material, structure, length, diameter, and tip shape, offering distinct advantages depending on the clinical context. Therefore, selecting the appropriate guidewire is crucial and must be tailored to the specific requirements of each procedure. This article provides a comprehensive review of the current landscape of guidewire use in biliopancreatic endoscopy, emphasizing their importance, characteristics, and best practices for selection to optimize patient outcomes. By reviewing existing guidelines and the literature, this paper aims to enhance the endoscopist's understanding of guidewire technology and its application in biliopancreatic endoscopy.

Effects of clinical donor characteristics on the success of faecal microbiota transplantation for patients in Denmark with Clostridioides difficile infection: a single-centre, prospective cohort study

BACKGROUND

Faecal microbiota transplantation (FMT) is an effective treatment for patients with recurrent Clostridioides difficile infection, but donor selection can influence its clinical success. We aimed to investigate the effect of clinical donor characteristics on FMT outcomes in patients with C difficile infection.

METHODS

In this single-centre, prospective cohort study, we included all donors who fulfilled the national criteria for faeces donation and delivered donations to the Centre for Faecal Microbiota Transplantation, Aarhus University Hospital, Denmark, between May 2, 2016, and Oct 31, 2023, and corresponding recipients treated with one-dose FMT for primary or recurrent C difficile infection. In mixed-effects models, we evaluated the effect of donor sex, age, BMI, smoking status, donation stool consistency, total donation weight, antibiotic use, Helicobacter pylori carriage, birth mode, donor-recipient sex concordance, and the alpha diversity of faeces donations on FMT outcomes in recipients. The primary outcome was the resolution of diarrhoea associated with C difficile infection in patients 8 weeks after FMT.

FINDINGS

Among 145 blood donors who also donated faeces, 115 (79·3%) were men and 30 (20·7%) were women. 90 (62·1%) provided faeces for 1351 evaluable FMTs in 952 patients with C difficile infection. 1037 (76·8%) FMTs were administered through oral capsules, 151 (11·2%) via colonoscopy, and 163 FMTs (12·1%) via nasojejunal tube. Antibiotic use 3-12 months before donation decreased the effectiveness of FMT (odds ratio 0·55 [95% CI 0·33-0·91]; p=0·019). Compared with donations with a Bristol Stool Form Scale (BSFS) score of 3, donations with a score of 4 (odds ratio 1·38 [95% CI 1·04-1·83]; p=0·024) and 5 or above (2·89 [1·33-6·26]; p=0·0072) showed improved FMT effectiveness. Donor sex, BMI, smoking status, H pylori carriage, birth mode, total donation weight, and donor-recipient sex concordance did not affect FMT outcomes.

INTERPRETATION

Expanding current donor selection criteria to avoid antibiotic use in the 12 months preceding donation and including donations with a BSFS score of 5 might improve FMT outcomes for patients with C difficile infection. Our findings call for the revision of current clinical donor screening practices, and future studies could further optimise the criteria for selecting optimal faeces donors.

FUNDING

Innovation Fund Denmark.

A New Drying Method of Thermolabile Flexible Endoscope Channels by Laminar and Turbulent Airflow: A Prospective, Randomized-Controlled, Single-Center, Proof-of-Concept Trial

INTRODUCTION

International guidelines suggest different possibilities for drying of endoscopes during reprocessing. Clinical results of these available drying methods are not satisfactory. The aim of this study was to compare the drying cycle of a standard endoscope washer-disinfector (EWD) (standard drying method [SD]) with a shortened mandatory drying by the EWD followed by a special drying device using laminar and turbulent air flow (novel drying method [ND]).

METHODS

Sixty endoscopes (duodenoscopes, colonoscocopes, and gastroscopes) from 3 different manufacturers underwent high-level disinfection and drying depending on the randomization group. Operational time of drying was measured for both groups. Residual fluid in the channels was measured using a laboratory scale. After a 14-day storage period, a sample of the endoscope channels was obtained to determine bacterial contamination.

RESULTS

ND had significantly fewer residual water in endoscope channels (SD: 90% vs ND: 0%; P < 0.001) after high-level disinfection and drying and less bacterial contamination after storage for 14 days (SD: 47% vs ND: 20%; P = 0.028). Time consumed for drying in ND was also significantly shorter (SD: 16 minutes 4 seconds vs ND: 5 minutes 59 seconds; P < 0.001).

DISCUSSION

Drying with a special automatic drying device was superior compared with an EWD's drying program as evidenced by no measurable residual water, reduced microbiological contamination, and a more than 2-fold decrease in operational time. Thus, drying by laminar and turbulent airflow may represent an attractive alternative to the currently used standard approach in the reprocessing process of flexible endoscopes.

Polysaccharides as submucosal injection materials (SIMs) in endoscopic resection: A comprehensive review

Submucosal injection materials (SIMs) play a vital role in the endoscopic treatment of benign and early malignant gastrointestinal lesions by effectively elevating lesions while significantly reducing the risks of thermal injury and bleeding. However, the traditional use of normal saline (NS) presents challenges due to its rapid absorption, which necessitates frequent reapplications and complicates procedural efficiency. Therefore, there is a pressing need for ideal SIMs that are cost-effective, readily available, and suitable for personalized therapy, while also demonstrating excellent biocompatibility and physicochemical stability. Recent advancements have highlighted the potential of polysaccharide-based natural polymers, such as sodium hyaluronate, cellulose, starch derivatives, chitosan, and sodium alginate, due to their superior biocompatibility and biodegradability. These polysaccharides have exhibited enhanced operational characteristics and therapeutic efficacy in animal and clinical studies. Nevertheless, ongoing research must address several challenges, including optimizing cost-effectiveness, improving mechanical strength and bioactivity, and mitigating intraoperative and postoperative complications. This review systematically examines the progress of polysaccharide-based natural polymers in SIMs, evaluates their current status and challenges in both research and clinical applications, and proposes future directions to enhance their utilization in gastrointestinal endoscopic therapy.

Role of Endoscopy in Clinical Management of Intraductal Papillary Mucinous Neoplasms

Intraductal papillary mucinous neoplasm (IPMN) of the pancreas is a well-recognized precursor of pancreatic carcinoma. Along with cross-sectional abdominal imaging tests, endoscopic examinations remain the cornerstone in the diagnosis of pancreatic cysts, early detection of IPMN-derived carcinomas, and risk stratification of patients with IPMNs for subsequent surveillance strategies. In particular, endoscopic ultrasound (EUS) facilitates the optimal patient management by providing high-resolution morphological information, and the contrast-enhanced harmonic mode may further enhance diagnostic accuracy. EUS-guided fine-needle aspiration for solid mass and/or cyst fluid is considered for pathological and molecular examinations for the diagnosis of pancreatic cysts and malignancy. Emerging evidence suggests the usefulness of through-the-needle biopsy and confocal laser microendoscopy in this setting. In addition to the undoubtful diagnostic utility, recent studies have demonstrated the potential effect of endoscopic interventions (i.e., ablation) on the control of IPMNs. Despite the increasing role of endoscopy in the clinical management of IPMNs, there remains a gap in our understanding of how to utilize endoscopy in the personalized care for patients with IPMNs (e.g., the optimal interval of EUS) and the prevention of deaths due to pancreatic carcinomas developing concomitantly with IPMNs. This review summarizes the current evidence on the role of endoscopy in both the diagnostic and therapeutic landscapes of clinical management of IPMNs and identifies key clinical unmet needs that should be addressed in future research. Combined with emerging technologies (e.g., artificial intelligence and high-throughput molecular profiling), endoscopy would offer more effective and tailored management strategies for patients with IPMNs.

Development and usability of an endoscopist report card assessing ERCP quality

BACKGROUND AND AIMS

Audit and feedback (A&F) for ERCP is relatively understudied despite the demonstrated effectiveness of A&F for endoscopic procedures such as colonoscopy. Endoscopist "report cards" are one such A&F tool. We aimed to develop an ERCP report card and assess its appropriateness, acceptability, and feasibility through usability testing.

METHODS

A prototype report card was designed using a combination of published quality indicators and established predictors of adverse events (AEs). Exploratory analyses from a prospective multicenter registry were performed to further identify novel and/or understudied parameters for possible inclusion. Semistructured interviews with ERCP endoscopists were conducted and framework analysis performed. Validated postinterview usability instruments were administered. Feedback was incorporated to create a final report card.

RESULTS

The report card included domains of technical parameters, AE rates and prevention, and patient-reported experience measures (PREMs). Qualitative feedback was positive, with respondents agreeing with inclusion of relevant content in most domains. Postinterview instruments revealed adequate appropriateness and acceptability. PREMs were believed by respondents to be poorly actionable and were replaced with appropriateness of indication and fluoroscopy usage parameters in the final report card. Concerns were raised regarding the feasibility of implementation because of reliance on difficult-to-obtain granular intraprocedural data.

CONCLUSIONS

We designed and tested an ERCP report card that has the potential to be an effective A&F intervention for endoscopists in clinical practice. Although feasibility of data capture and implementation are currently limitations, advances in video recording and artificial intelligence technologies could accelerate widespread adoption of such a tool.

Fecal Secretory Immunoglobulin A and Lactate Level as a Biomarker of Mucosal Immune Dysfunction in Horses With Colic

BACKGROUND

Colic-related obstructions can reduced intestinal mucosa function and cause dysbiosis in horses, but it is unclear how defense barrier and secretory immunoglobulin A (SIgA) secretion is disrupted.

OBJECTIVES

The aim of the study is to evaluate the effect of severity of colic signs and treatments on fecal SIgA and fecal lactate in horses.

ANIMALS

Sixty-two client owned hospitalised horses with colic and eight healthy horses.

METHODS

Prospective clinical trial. Fecal samples were taken daily for 7 days. SIgA was analyzed using ELISA, and D/L-lactate measured with a commercial kit.

RESULTS

At Day 0, SIgA values in the colic medical and colic surgical groups were significantly higher than in the control stable group (U = 126.0, p = 0.099, Cliff's ∆ = 0.58 and U = 248.0, p = 0.005, Cliff's ∆ = 0.72, respectively). We found significant correlation between fecal SIgA and fecal lactate level in D0 (rs = 0.421, p = 0.038).

CONCLUSIONS

This study demonstrates the feasibility of using fecal samples to identify biomarkers of colic in horses. An increase in fecal SIgA in horses with colic might suggest the presence of inflammation within the intestines and disruption of the mucosal barrier. These data highlight changes in gastrointestinal barrier and immune function and the intestinal microbiota's metabolic activity in horses with colic.

Endohepatology: Applications in Liver Transplant

The term "endohepatology" was coined over the last 15 years to describe the integration of interventional endoscopy and hepatology for the management of patients with chronic liver disease. In this article, we will review the diagnostic and therapeutic applications of endoscopic ultrasound and endoscopic retrograde cholangiopancreatography among liver transplantation candidates and recipients.

Multisociety guidance for sterilization and high-level disinfection

SHEA, in partnership with ASGE, APIC, AAMI, AORN, HSPA, IDSA, SGNA, and The Joint Commission, developed this multisociety infection prevention guidance document for individuals and organizations that engage in sterilization or high-level disinfection (HLD). This document follows the CDC Guideline for Disinfection and Sterilization in Healthcare Facilities. This guidance is based on a synthesis of published scientific evidence, theoretical rationale, current practices, practical considerations, writing group consensus, and consideration of potential harm when applicable. The supplementary material includes a summary of recommendations. The guidance provides an overview of the Spaulding Classification and considerations around manufacturers' instructions for use (MIFUs). Its recommendations address: point-of-use treatment prior to sterilization or HLD, preparation of reusable medical devices at the location of processing, sterilization, and immediate use steam sterilization (IUSS), HLD of lumened and non-lumened devices, processing of reusable medical devices used with lubricating or defoaming agents, monitoring for effectiveness of processing, handling of devices after HLD, augments and alternatives to HLD, processing of investigational devices, tracking of reusable medical devices, and approaches to implementation.

Impact of Different Pressures on the Drying Time of Flexible Endoscopes

BACKGROUND

The complex structure of endoscopes causes nonuniform drying conditions. However, current clinical drying practices lack precise guidance, leading to the insufficient drying of some endoscopes, which increases the risk of infection. The pressure of compressed air has been proven to affect the effectiveness of endoscope drying; however, specific requirements are absent. This study explored the time required for the sufficient drying of different endoscopes under various pressure conditions.

METHODS

Six different types of commonly used Olympus flexible endoscopes were selected, and for each type, multiple drying time groups were set under pressures of 0.102 and 0.204 MPa, with 10 endoscopes observed in each group.

RESULTS

Drying times varied according to the type and pressure. At 0.102 MPa, the instrument channel drying ranged from 80 s to 160 s (avg. 123 s), while suction channel ranged from 260 s to 540 s (avg. 428 s). At 0.204 MPa, the instrument channel dried in 50 s to 90 s (avg. 72 s), and suction channel in 130 s to 230 s (avg. 186 s).

CONCLUSIONS

Optimal drying times for endoscopes differ according to the type and pressure. A higher pressure (0.204 MPa) efficiently removes moisture and speeds up drying. Longer endoscopes with the same biopsy channel diameter require longer drying time. In addition, the instrument channel dries faster than the suction channel.

Histologic Diagnosis of Pancreatic Cystic Lesions with Endoscopic Ultrasound Fine Needle Biopsy and Impact on Management Decisions

PURPOSE

Endoscopic ultrasound with fine needle biopsy (EUS-FNB) has not been well studied in pancreatic cystic lesions (PCLs). This study evaluates the diagnostic performance of EUS-FNB for PCLs and its impact on management decisions.

METHODS

We conducted a single-center, retrospective study of patients who had EUS-FNB between March 2016 and February 2024. We included patients with ≥ 6-month follow-up and excluded those with a solid pancreatic mass. We obtained clinical, radiologic, endoscopic, surgical, laboratory, and pathology data from chart review. We evaluated: (A) diagnostic yield; (B) predictors of diagnostic FNB; (C) diagnostic accuracy compared to surgical histopathology; (D) appropriateness of management decisions; and (E) adverse events. We compared the appropriateness of management decisions between diagnostic and non-diagnostic FNB.

RESULTS

100 subjects underwent EUS-FNB for PCLs (56% microcystic or with mural nodule). FNB yielded a histologic diagnosis in 60% of sampled lesions. Performing 2 or more needle passes was the only significant predictor of a diagnostic FNB (p = 0.02). Compared to surgical histopathology (n = 21), FNB needles highly accurately diagnosed specific cyst types (IPMN = 85.7%, MCN = 90.5%, SCA = 95.2%, NET = 95.2%, SPN = 100%) and malignant PCLs (accuracy = 81.0%; specificity = 100%; sensitivity = 72.7%). There was a 7.2-fold increase of appropriate management decisions when FNB was diagnostic vs. non-diagnostic (p < 0.001). This was due to improvement in surveillance discontinuation for benign cysts and in appropriate surgical resection for malignant PCLs (p < 0.001). Post-FNB pancreatitis occurred in 4% of patients.

CONCLUSION

EUS-FNB accurately diagnoses different PCL types and their degree of neoplasia, leading to more appropriate management decisions. Future prospective studies are needed to confirm these findings.

Natural history and management of IPMN in solid organ transplant patients: is it any different?

BACKGROUND

Intraductal papillary mucinous neoplasms (IPMNs) are premalignant lesions with established surveillance and surgical resection guidelines. This systematic review aims to provide evidence-based guidance for managing IPMNs in transplant patients.

METHODS

A search of MEDLINE, Embase, and Scopus identified studies published between January 1, 2004, and July 31, 2024, describing transplant candidates or recipients with IPMNs. Covidence software was used to screen and synthesize articles. Data were reviewed to determine whether IPMNs should preclude transplant, delay listing, require different surveillance, necessitate adjusted immunosuppression, or affect surgical complexity or cancer conversion rates.

RESULTS

Seventeen studies involving 7023 transplant patients, including 339 with suspected or confirmed IPMNs (4.82 %), were analyzed. No evidence suggested IPMNs should preclude transplant candidacy or delay listing. IPMN surveillance guidelines for transplant patients should align with those for non-transplant patients. Transplant recipients did not experience higher rates of IPMN conversion to pancreatic cancer, indicating no need to modify immunosuppression.

CONCLUSION

This qualitative systematic review found no evidence that the natural history or management of IPMNs differs between transplant and non-transplant patients, suggesting no need for special management in transplant populations.

After stent placement in patient with left colon cancer with intestinal obstruction safety and efficacy analysis

PURPOSE

This study aimed to evaluate the safety and efficacy of intestinal stent placement as a bridge to surgery in patients with left colon cancer complicated by intestinal obstruction (LCCO).

METHODS

A retrospective cohort analysis was conducted on 111 patients diagnosed with LCCO at The Second Affiliated Hospital of Chongqing Medical University between January 2015 and August 2019. Patients were divided into two groups: the stent group (SG, n = 41) and the emergency surgery group (EG, n = 70). Primary endpoints included 3-year progression-free survival (PFS), local recurrence, and distant metastasis rates. Secondary endpoints encompassed 3-year overall survival (OS), intraoperative parameters (lymph node dissection, blood loss, operative time), enterostomy rate, postoperative complications, and hospital stay duration.

RESULTS

No significant differences were observed between SG and EG in 3-year PFS (59% vs. 41%, P = 0.091), OS (61% vs. 44%, P = 0.051), or metastasis rates (19.5% vs. 20%, P = 0.95). However, SG demonstrated superior short-term outcomes, including reduced intraoperative blood loss (60 mL vs. 78 mL, P = 0.02), shorter hospital stay (10.2 vs. 16.1 days, P < 0.001), lower enterostomy rate (0% vs. 100%, P < 0.001), and fewer postoperative complications (14.6% vs. 24.3%, P = 0.012).

CONCLUSION

Stenting in patients with left colon cancer with obstruction can relieve the symptoms of intestinal obstruction in time. Compared with emergency open surgery, it has better short-term results and does not affect the long-term curative effect of the tumor.

Higher Inpatient Racial and Ethnic Diversity Is Associated with Better Outcomes in Hispanic and Native American Patients for Gastrointestinal Diseases

BACKGROUND

Evidence suggests that outcomes are poorer among patients from historically marginalized racial and ethnic backgrounds. The impact of patient racial and ethnic diversity on gastrointestinal outcomes is understudied.

AIMS

To investigate the impact of patient racial/ethnic diversity on gastrointestinal disease (GI) outcomes.

METHODS

Using the 2019 National Inpatient Sample (NIS), hospital inpatient racial/ethnic diversity was defined as the percentage of Hispanic or Native American discharges. We included gastrointestinal bleeding, inflammatory bowel diseases, gastrointestinal obstruction, cirrhosis, and alcohol-associated hepatitis. Logistic regression was used to predict outcomes [major complications (MCC), long length of stay, high total charges], controlling for age, gender, location, income quartile, hospital size, and region.

RESULTS

Our cohort included 537,830 hospitalizations. In the unadjusted analyses, MCC rates were higher among Hispanic (24.8%) and Native American patients (30.4%), compared to Whites (18.3%). In adjusted analyses, compared to Whites, Hispanic [adjusted odds ratio (OR) 1.21, 95% Confidence Interval (CI) 1.15-1.28] and Native American patients [OR 1.25, (95% CI) 1.09-1.43] had higher MCC rates. As hospital Hispanic diversity increased, MCC for Hispanics improved [OR 0.93, (95% CI) 0.87-1.14] and were even better among Native American patients as their diversity increased [OR 0.83, (95% CI) 0.73-0.94] (Table 1). A similar trend was observed in the 2018 validation cohort.

CONCLUSION

Increasing hospital inpatient Hispanic and Native American diversity is associated with better outcomes for these groups. Further research is needed on the impact cultural competence and linguistic concordance on gastrointestinal outcomes.

Diagnostic performance of AI-assisted endoscopy diagnosis of digestive system tumors: an umbrella review

The diagnostic performance of artificial intelligence (AI)-assisted endoscopy for digestive tumors remains controversial. The objective of this umbrella review was to summarize the comprehensive evidence for the AI-assisted endoscopic diagnosis of digestive system tumors. We grouped the evidence according to the location of each digestive system tumor and performed separate subgroup analyses on the basis of the method of data collection and form of the data. We also compared the diagnostic performance of AI with that of experts and nonexperts. For early digestive system cancer and precancerous lesions, AI showed a high diagnostic performance in capsule endoscopy and esophageal squamous cell carcinoma. Additionally, AI-assisted endoscopic ultrasonography (EUS) had good diagnostic accuracy for pancreatic cancer. In the subgroup analysis, AI had a better diagnostic performance than experts for most digestive system tumors. However, the diagnostic performance of AI using video data requires improvement.

Management of severe and fulminant Clostridioides difficile infection in adults

Clostridioides difficile (formerly known as Clostridium difficile) is a significant cause of healthcare-associated infection with symptoms ranging from diarrhoea and abdominal pain to pseudomembranous colitis and toxic megacolon. Severe disease can pose a significant morbidity and mortality risk and is to be considered a medical emergency. The emergence of a new C. difficile ribotype with an estimated mortality rate of 20% (ribotype 995) has prompted a re-review of the evidence and guidelines around managing severe C. difficile infections (CDI). International guidance on the management of CDI varies regarding first-line antibiotic choice. Metronidazole is no longer favoured as first line due to concerns around resistance, and vancomycin and fidaxomicin are now recommended as first line options. Antibiotic therapy should be used in conjunction with good supportive measures and early consideration of surgical management. Faecal microbiota transplant can be utilized in recurrent CDI and may be useful in severe disease. Severe CDI is a significant ongoing threat to public health, and further research into effective management is essential to ensure the best possible outcomes for patients.

Important Anatomy in Lymphatic Interventions: A Practical Review

New understanding of the lymphatic system as well as increasing recognition of its importance in various pathologies have increased the opportunity to perform lymphatic interventions. Advancement in our understanding of the lymphatic system anatomy, including variations, combined with improved imaging has renewed interest in both surgical and interventional management of a wide range of complex lymphatic pathologies. It is important for the proceduralist to recognize the anatomy, variability, and physiology of the lymphatic system, including lower extremity lymphatic drainage, cisterna chyli location, and thoracic duct drainage. The purpose of this study is to convey the practical aspects of performing lymphatic interventions in an effort to improve the speed and reliability of these procedures.

Progresses in Questing for the Truth of Opioid-Related Constipation in Cancer Patients

Opioids are extensively utilised to manage pain in cancer patients, but may cause constipation which significantly impacts their prognosis and quality of life. Opioid-induced constipation (OIC) lacks effective drugs and management strategies. Opioids act on the enteric nervous system, intestinal barrier, intestinal immunity and intestinal microbiota, implying that OIC is a multifactorial process. This paper aims to examine the effects of opioids on the intestine, specifically the enteric nervous system, intestinal barrier and interstitial cells of Cajal (ICCs), and elucidate the primary mechanisms underlying OIC development and deterioration. This review suggests that enteric neurons, intestinal immunity and intestinal flora could serve as potential therapeutic targets for OIC.

Hepatology in the Digital Era: A Review of Telehealth Care for Liver Disease

PURPOSE OF REVIEW

Telehealth has become an integral component of healthcare delivery in the US. While telehealth has been utilized within Hepatology for decades for HCV through Project ECHO and adapted by the VA, the COVID-19 pandemic catalyzed an unprecedented expansion of telehealth. This review examines the evolution, benefits, challenges, and future implications of telehealth in Hepatology.

RECENT FINDINGS

Telehealth can improve access to care for underserved patient populations and provide continuity of care for chronic liver disease and liver transplant patients. Studies suggest that telehealth can deliver equivalent quality of care to in-person visits with high satisfaction rates among patients and providers. However, there are barriers to telehealth including disparities in technology access, limitations in quality of virtual encounters, and limited insurance policies. However, many questions remain. As Hepatology enters the digital era, telehealth holds promise for enhancing care delivery, but its integration must be guided by evidence-based practices.

Long-term clinical outcomes of pancreatic cystic lesions in liver transplant patients

BACKGROUND

Pancreatic cystic lesions (PCL) are often incidentally diagnosed in transplant patients, although long-term impact in this chronically immunosuppressed population remains unclear. This study examines long-term malignant potential and outcomes of PCL in orthotopic liver transplant (OLT) patients.

METHODS

A retrospective study of 1110 patients who underwent OLT from 2011 to 2017 at a tertiary referral center was performed. Demographic, imaging, and outcomes data were examined.

RESULTS

86 OLT patients with 148 PCL were identified. Median follow up after PCL identification was 7.6 years (IQR 5.7-9.7). Most cysts decreased in size (45%) or remained stable (30.2%). Only 24% of PCL increased in size, with average growth of 2.7 mm/year. Based on American College of Gastroenterology (ACG) 2018 guidelines, 20 patients (23%) developed high-risk imaging characteristics. Of 16 endoscopic ultrasounds (EUS) performed, 1 patient was diagnosed with pancreatic adenocarcinoma. There were no pancreas-specific causes of death and no survival differences in OLT patients with and without PCL on multivariate analysis.

CONCLUSION

There is a low incidence of malignant transformation of PCL in OLT patients and no survival disadvantage at long-term follow up despite immunosuppression. PCL in OLT patients should be managed under similar guidelines as immunocompetent patients.

Fecal microbiota transplantation: application scenarios, efficacy prediction, and factors impacting donor-recipient interplay

Fecal microbiota transplantation (FMT) represents a therapeutic approach that directly regulates the gut microbiota of recipients, normalizes its composition and reaping therapeutic rewards. Currently, in addition to its general application in treating Clostridium difficile (C. difficile) infection (CDI), FMT treatment has also been extended to the fields of other gastrointestinal diseases, infections, gut-liver or gut-brain axis disorders, metabolic diseases and cancer, etc. Prior to FMT, rigorous donor screening is essential to reduce the occurrence of adverse events. In addition, it is imperative to evaluate whether the recipient can safely and effectively undergo FMT treatment. However, the efficacy of FMT is influenced by the complex interactions between the gut microbiota of donor and recipient, the degree of donor microbiota engraftment is not necessarily positively related with the success rate of FMT. Furthermore, an increasing number of novel factors affecting FMT outcomes are being identified in recent clinical trials and animal experiments, broadening our understanding of FMT treatment. This article provides a comprehensive review of the application scenarios of FMT, the factors influencing the safety and efficacy of FMT from the aspects of both the donors and the recipients, and summarizes how these emerging novel regulatory factors can be combined to predict the clinical outcomes of patients undergoing FMT.

Complications of Endoscopic Retrograde Cholangiopancreatography

Up to 1 in 6 patients will experience an unplanned hospitalization after endoscopic retrograde cholangiopancreatography (ERCP), largely for the evaluation and management of adverse events. Therefore, a commitment to the prevention, early recognition, and effective rescue of complications related to ERCP is critical toward improving outcomes. ERCP is most often complicated by acute pancreatitis, bleeding, infection, or perforation, although myriad other adverse events may occur. The prevention of post-ERCP pancreatitis has been the area of greatest interest and progress in the last decade, but the application of evidence-based prophylactic measures remains inconsistent. Innovations in stent, hemostasis, and perforation closure technology now allow effective and efficient endoscopic management of several important nonpancreatitis complications. Overall, our ability to prevent and treat ERCP-related adverse events has improved substantially, amplifying the importance of a high level of suspicion for and a thorough understanding of these events.

Changes in provider responsibilities and associated outcomes for cirrhotic patients with telehealth: A single-center, retrospective study

BackgroundStudies show satisfaction with telemedicine, but there is limited data regarding changes in provider practices and clinical outcomes. We sought to evaluate the impact of telehealth on patient-provider communications between visits and clinical outcomes in patients with cirrhosis during the COVID-19 pandemic.MethodsSingle-center retrospective study of cirrhotic patients seen outpatient in 2019 and 2020 was conducted. Clinical characteristics, provider practices, and clinical outcomes were obtained. Provider practices included medication adjustments, labs ordered, and patient communication. Clinical outcomes included ED visits, hospitalizations, and mortality.ResultsTotally, 1395 patients were included with a mean age of 61, 51% female, and 73% Caucasian. The median baseline model for end-stage liver disease (MELD-Na) score was 10. During 2019 there were no telehealth visits. In 2020, 37% of clinic visits were telehealth and 64% of patients had at least one telehealth visit. The rate of medication changes significantly decreased in 2020. There was no significant difference in number of clinic visits, labs ordered, emergency department visits, hospitalizations, or intensive care unit (ICU) stays between 2019 and 2020. In 2020, the rate of telephone contacts and patient messages significantly increased. Compared to 2019, the odds of death were 2.6 times higher in 2020.ConclusionWhen a majority of cirrhotic patients had a telehealth visit, patients had similar rates of emergency department visits, hospitalizations, and ICU stays, but a higher rate of mortality compared to patients with in-person visits. Telehealth was associated with more patient contact between visits, increasing communication demands on providers.

Recent advances in nanotherapeutics for HIV-associated neurocognitive disorders and substance use disorders

Substance use disorders (SUD) and HIV-associated neurocognitive disorders (HAND) work synergistically as a significant cause of cognitive decline in adults and adolescents globally. Current therapies continue to be limited due to difficulties crossing the blood-brain barrier (BBB) leading to limited precision and effectiveness, neurotoxicity, and lack of co-treatment options for both HAND and SUD. Nanoparticle-based therapeutics have several advantages over conventional therapies including more precise targeting, the ability to cross the BBB, and high biocompatibility which decreases toxicity and optimizes sustainability. These advantages extend to other neurological disorders such as Alzheimer's disease (AD) and amyotrophic lateral sclerosis (ALS). This review summarizes recent advances in nanotechnology for application to HAND, SUD, and co-treatment, as well as other neurological disorders. This review also highlights the potential challenges these therapies face in clinical translation and long-term safety.

Adverse Events Associated With Endoscopic Retrograde Cholangiopancreatography: Systematic Review and Meta-Analysis

BACKGROUND & AIMS

Endoscopic retrograde cholangiopancreatography (ERCP)-related adverse events (AEs) are associated with morbidity, mortality, and health care expenditure. We aimed to assess incidences and comparisons of ERCP AEs.

METHODS

We included studies performed after 2000 reporting on ERCP AEs from database inception through March 12, 2024. Outcomes included pancreatitis, bleeding, cholangitis, cholecystitis, perforation, and death. DerSimonian and Laird random effects meta-analyses were performed to calculate incidences of AEs. Subgroup and pairwise meta-analyses were performed. Meta-regression was performed on median recruitment year to assess temporal trends in pancreatitis incidence.

RESULTS

A total of 380 studies were included. The incidence of death attributable to ERCP was 0.2% (95% confidence interval [CI], 0.1%-0.3%; I2, 44%; n = 47,258) in all-comers. The overall incidence of pancreatitis was 4.6% (95% CI, 4.0%-5.1%; I2, 96%; n = 293,378) among all-comers and 6.5% (95% CI, 5.9%-7.1%, I2, 89%; n = 88,809) among first-time patients. Pancreatitis incidence remained stable between 2000 and 2023 (average annual percent change 0.06, 95% CI, -0.27 to 0.39). The overall incidences of the following AEs for all-comers were: bleeding (1.5%; 95% CI, 1.2%-1.7%; I2, 93%; n = 229,655), cholangitis (2.5%; 95% CI, 1.9%-3.3%; I2, 96%; n = 121,619), cholecystitis (0.8%; 95% CI, 0.5%-1.2%; I2, 39%; n = 7799), and perforation (0.5%; 95% CI, 0.4%-0.6%; I2, 90%; n = 306,378).

CONCLUSIONS

ERCP-associated AEs remain common. Incidence of post-ERCP pancreatitis remained static despite improvements in techniques, prevention, and recognition. These results are important to patients, endoscopists, and policy makers to inform consent and to encourage implementation of available risk mitigation strategies.

The microbiome's influence on obesity: mechanisms and therapeutic potential

In 2023, the World Obesity Atlas Federation concluded that more than 50% of the world's population would be overweight or obese within the next 12 years. At the heart of this epidemic lies the gut microbiota, a complex ecosystem that profoundly influences obesity-related metabolic health. Its multifaced role encompasses energy harvesting, inflammation, satiety signaling, gut barrier function, gut-brain communication, and adipose tissue homeostasis. Recognizing the complexities of the cross-talk between host physiology and gut microbiota is crucial for developing cutting-edge, microbiome-targeted therapies to address the global obesity crisis and its alarming health and economic repercussions. This narrative review analyzed the current state of knowledge, illuminating emerging research areas and their implications for leveraging gut microbial manipulations as therapeutic strategies to prevent and treat obesity and related disorders in humans. By elucidating the complex relationship between gut microflora and obesity, we aim to contribute to the growing body of knowledge underpinning this critical field, potentially paving the way for novel interventions to combat the worldwide obesity epidemic.

Intra- and post-procedural patient-reported experience measures and their correlation with post-ERCP adverse events and unplanned healthcare utilization

BACKGROUND

 Post-endoscopic retrograde cholangiopancreatography (ERCP) adverse events (AEs) are common, as is unplanned healthcare utilization (UHU). We aimed to assess potential etiologic associations between intra-/post-procedural patient-reported experience measures (PREMs) and post-ERCP AEs and UHU. METHODS : Prospective data from a multicenter collaborative were used. A 0-10 Likert-based PREM assessing intra- and post-procedural symptoms was applied to patients following ERCP, and follow-up was performed at 30 days to identify AEs and UHU for reasons not meeting the definitions of any AE. Multivariable logistic regression was conducted using PREM domains as exposures and AEs and UHU as outcomes, with a priori selected covariates. Odds ratios (ORs) and 95 %CIs for each PREM domain were reported.

RESULTS

 From 2018 to 2023, 3434 patients were included. A post-procedural abdominal pain score > 3 was associated with pancreatitis (OR 3.71 [95 %CI 2.37-5.73]), while a score > 6 was associated with perforation (OR 9.54 [95 %CI 1.10-59.37]). Post-procedural pain was also associated with UHU within 30 days when used as a continuous exposure (OR 1.08 per point [95 %CI 1.01-1.16]), and when partitioned at a score > 3 (OR 1.79 [95 %CI 1.13-2.74]) and a score > 6 (OR 1.93 [95 %CI 1.02-3.46]). No other intra- or post-procedural PREMs were associated with any AEs or UHU.

CONCLUSIONS

 Patient-reported abdominal pain from a Likert-based PREM at the time of discharge from ERCP was associated with pancreatitis, perforation, and UHU within 30 days. Applying PREMs could potentially prevent UHU and/or facilitate earlier management and improved outcomes for patients with post-ERCP AEs.

The always evolving diagnosis and management of Clostridioides difficile colitis: What you need to know

ABSTRACT

The diagnosis, pharmacologic management, and surgical options for Clostridioides difficile infection (CDI) are rapidly evolving, which presents a challenge for the busy surgeon to remain up to date on the latest clinical guidelines. This review provides an evidence-based practical guide for CDI management tailored to the needs of surgeons and surgical intensivists. Historically, the diagnosis of CDI relied on slow cell culture cytotoxicity neutralization assays, but now, the rapidly resulting nucleic acid amplification tests and enzyme immunoassays have become mainstream. In terms of antibiotic therapy, metronidazole and oral vancomycin were the main "workhorse" antibiotics in the early 2000s, but large randomized controlled trials have now demonstrated that fidaxomicin produces superior results. Regarding surgical intervention, total abdominal colectomy was once the only procedure of choice; however, diverting loop ileostomy with colonic lavage is emerging as a viable alternative. Finally, novel adjuncts such as fecal microbiota transplantation and targeted therapy against toxin B (bezlotoxumab) are playing an increasingly important role in the management of CDI.

Proteomic meta-analysis unveils new frontiers for biomarkers research in pancreatic carcinoma

Pancreatic carcinoma (PC) is the sixth leading cause of cancer death in both sexes in 2022, responsible for almost 5% of all cancer deaths worldwide; it is characterized by a poor prognosis since most patients present with an unresectable and metastatic tumor. To date, the decreasing trend in mortality rates related to the most common cancers has contributed to making pancreatic cancer a serious public health problem. In the last few years, scientific research has led to many advances in diagnostic approaches, perioperative management, radiotherapy techniques, and systemic therapies for advanced disease, but only with modest incremental progress in PC patient outcomes. Most of the causes of this high mortality are, unfortunately, late diagnosis and an important therapeutic resistance; for this reason, the most recent high-throughput proteomics technologies focus on the identification of novel biomarkers and molecular profiling to generate new insights in the study of PC, to improve diagnosis and prognosis and to monitor the therapies progress. In this work, we present and discuss the integration of results from different revised studies on protein biomarkers in a global proteomic meta-analysis to understand which path to pursue scientific research. In particular, cancer signaling, inflammatory response, and cell migration and signaling have emerged as the main pathways described in PC, as well as scavenging of free radicals and metabolic alteration concurrently highlighted new research insights on this disease. Interestingly, from the study of upstream regulators, some were found to be shared by collecting data relating to both biological fluid and tissue biomarkers, side by side: specifically, TNF, LPS, p38-MAPK, AGT, miR-323-5p, and miR-34a-5p. By integrating many biological components with their interactions and environmental relationships, it's possible to achieve an in-depth description of the pathological condition in PC and define correlations between concomitant symptoms and tumor genesis and progression. In conclusion, our work may represent a strategy to combine the results from different studies on various biological samples in a more comprehensive way.

Impacts of Antiretroviral Therapy on the Oral Microbiome and Periodontal Health of Feline Immunodeficiency Virus-Positive Cats

Feline immunodeficiency virus (FIV) is the domestic cat analogue of HIV infection in humans. Both viruses induce oral disease in untreated individuals, with clinical signs that include gingivitis and periodontal lesions. Oral disease manifestations in HIV patients are abated by highly effective combination antiretroviral therapy (cART), though certain oral manifestations persist despite therapy. Microorganisms associated with oral cavity opportunistic infections in patients with HIV cause similar pathologies in cats. To further develop this model, we evaluated characteristics of feline oral health and the oral microbiome during experimental FIV infection over an 8-month period following cART. Using 16S rRNA sequencing, we evaluated gingival bacterial communities at four timepoints in uninfected and FIV-infected cats treated with either cART or placebo. Comprehensive oral examinations were also conducted by a veterinary dental specialist over the experimental period. Gingival inflammation was higher in FIV-infected cats treated with placebo compared to cART-treated cats and the controls at the study endpoint. Oral microbiome alpha diversity increased in all groups, while beta diversity differed among treatment groups, documenting a significant effect of cART therapy on microbiome community composition. This finding has not previously been reported, and indicates cART ameliorates immunodeficiency virus-associated oral disease via the preservation of oral mucosal microbiota. Further, this study illustrates the value of the FIV animal model for investigations of mechanistic associations and therapeutic interventions for HIV's oral manifestations.

Comparison of time-to-event machine learning models in predicting biliary complication and mortality rate in liver transplant patients

Post-Liver transplantation (LT) survival rates stagnate, with biliary complications (BC) as a major cause of death. We analyzed longitudinal data with a median 19-month follow-up. BC was diagnosed with ultrasounds and MRCP. Missing data was imputed using mean and median. Data preprocessing involved feature scaling and one-hot encoding. Survival analysis used filter (Cox-P, Cox-c) and embedded (RSF, LASSO) feature selection methods. Seven survival machine learning algorithms were used: LASSO, Ridge, RSF, E-NET, GBS, C-GBS, and FS-SVM. Model development employed 5-fold cross-validation, random oversampling, and hyperparameter tuning. Random oversampling addressed data imbalance. Optimal hyperparameters were determined based on average C-index. Features importance was assessed using standardized regression coefficients and permutation importance for top models. Stability was evaluated using 5-fold cross-validation standard deviation. Finally, 1799 observations with 40 outcome predictors were included. RSF with Ridge achieved the highest performance (C-index: 0.699) for BC prediction, while RSF with RSF had the highest performance (C-index: 0.784) for mortality prediction. Top BC predictors were LT graft types, IBD in recipients, recipient's BMI, recipient's history of PVT, and previous LT history. For mortality, they were post-transplant AST, creatinine, recipient's age, post-transplant ALT, and tacrolimus consumption. We identified BC and mortality risk factors, improving decision-making and outcomes.

Could intratumoural microbiota be key to unlocking treatment responses in hepatocellular carcinoma?

Hepatocellular carcinoma (HCC) is the third cause of cancer-related mortality worldwide. Current treatments include surgery and immunotherapy with variable response. Despite aggressive treatment, disease progression remains the biggest contributor to mortality. Thus, there is an urgent unmet need to improve current treatments through a better understanding of HCC tumourigenesis. The gut microbiota has been intensively examined in the context of HCC, with evidence showing gut modulation has the potential to modulate tumourigenesis and prognosis. In addition, recent literature suggests the presence of an intratumoural microbiota that may exert significant impacts on the development of solid tumours including HCC. By drawing parallels between the gut and hepatic/tumoural microbiota, we explore in the present review how the hepatic microbiota is established, its impact on tumourigenesis, and how modulation of the gut and hepatic microbiota may be key to improving current treatments of HCC. In particular, we highlight key bacteria that have been discovered in HCC tumours, and how they may affect the tumour immune microenvironment and HCC tumourigenesis. We then explore current therapies that target the intratumoural microbiota. With a deeper understanding of how the intratumoural microbiota is established, how different bacteria may be involved in HCC tumourigenesis, and how they can be targeted, we hope to spark future research in validating intratumoural microbiota as an avenue for improving treatment responses in HCC.

Thirty-day hospital admission following high-risk outpatient ERCP: incidence and analysis of risk factors based on a secondary analysis of the Stent Versus Indomethacin trial data set

BACKGROUND AND AIMS

ERCP carries potential for serious adverse events, and there is risk for unplanned health encounters after the procedure. The primary objective of this study was to identify the rate of 30-day hospital admission after outpatient ERCP in patients at elevated risk for post-ERCP pancreatitis based on patient- and procedure-related risk factors. We also explored whether pancreatitis rates and lengths of hospital stay differ with delayed hospitalization (versus admission immediately after ERCP) and identified factors associated with 30-day hospital admission.

METHODS

High-risk patients in the Stent Versus Indomethacin trial who underwent outpatient ERCP were identified. The primary outcome was hospital admission within 30 days after outpatient ERCP. Patient and procedural factors associated with 30-day hospital admission were explored by means of univariable analysis followed by multivariable analysis, controlling for potential known confounders.

RESULTS

Among 768 patients at high risk for post-ERCP pancreatitis who underwent outpatient ERCP and were discharged home, 21.9% required hospitalization within 30 days. Compared with patients who underwent outpatient ERCP but were admitted immediately to the hospital after the procedure, patients who were discharged after ERCP and admitted later had a higher incidence of post-ERCP pancreatitis (40.5% vs 30.9%; P = .04), moderate to severe post-ERCP pancreatitis (24.4% vs 13.8%; P < .01), and longer length of hospital stay (6.2 d vs 3.7 d; P < .001). Factors associated with 30-day hospitalization included patient age (odds ratio [OR], 0.98; 95% CI, 0.97-0.99), biliary stent placement (OR, 1.62; 95% CI, 1.05-2.48), and attempt at pancreatic duct cannulation (OR, 1.64; 95% CI, 1.02-2.64).

CONCLUSIONS

High-risk patients who undergo outpatient ERCP and are discharged home are at considerable risk for hospital admission within 30 days and have an increased rate of pancreatitis and longer length of hospital stay compared with outpatients admitted to the hospital immediately after ERCP, and some factors may predict this outcome. These findings should influence decision making and informed consent when electing to proceed with high-risk ERCP, recognizing that patients with sphincter of Oddi dysfunction were over-represented in this cohort, which may limit generalizability to a typical ERCP practice.

Current status and future direction of cancer research using artificial intelligence for clinical application

The expectations for artificial intelligence (AI) technology have increased considerably in recent years, mainly due to the emergence of deep learning. At present, AI technology is being used for various purposes and has brought about change in society. In particular, the rapid development of generative AI technology, exemplified by ChatGPT, has amplified the societal impact of AI. The medical field is no exception, with a wide range of AI technologies being introduced for basic and applied research. Further, AI-equipped software as a medical device (AI-SaMD) is also being approved by regulatory bodies. Combined with the advent of big data, data-driven research utilizing AI is actively pursued. Nevertheless, while AI technology has great potential, it also presents many challenges that require careful consideration. In this review, we introduce the current status of AI-based cancer research, especially from the perspective of clinical application, and discuss the associated challenges and future directions, with the aim of helping to promote cancer research that utilizes effective AI technology.

Innovative approaches in colorectal cancer screening: advances in detection methods and the role of artificial intelligence

Colorectal cancer (CRC) is the third most prevalent cancer globally and poses a significant health threat, making early detection crucial. This review paper explored emerging detection methods for early screening of CRC, including gut microbiota, metabolites, genetic markers, and artificial intelligence (AI)-based technologies. Current screening methods have their respective advantages and limitations, particularly in detecting precursors. First, the importance of the gut microbiome in CRC progression is discussed, highlighting how specific microbial alterations can serve as biomarkers for early detection, potentially enhancing diagnostic accuracy when combined with traditional screening methods. Next, research on metabolic reprogramming illustrates the relationship between metabolic changes and CRC, with studies developing metabolite-based detection models that show good sensitivity for early diagnosis. In terms of genetic markers, methylated DNA markers like SEPTIN9 have demonstrated high sensitivity, although further validation across diverse populations is necessary. Lastly, AI technology has shown immense potential in improving adenoma detection rates, significantly enhancing the quality of colonoscopic examinations through image recognition techniques. This review aims to provide a comprehensive perspective on new strategies for CRC screening, emphasizing the potential of noninvasive detection technologies and the prospects of AI and genomics in clinical applications. Despite several challenges, this review advocates for future large-scale prospective studies to validate the effectiveness and cost-effectiveness of these new screening methods while promoting the implementation of screening protocols tailored to individual characteristics.

Endoscopic hemostasis with a self-expandable metal stent as bridge therapy for hemobilia

Background and study aims

Management of hemobilia is often challenging. Recently, endoscopic hemostasis with a self-expandable metal stent (SEMS) has shown promising efficacy for controlling bleeding at the endoscopic sphincterotomy site. This study aimed to assess efficacy and feasibility of endoscopic hemostasis as bridge therapy for hemobilia.

Patients and methods

Patients with hemobilia between 2008 and 2023 were retrospectively reviewed. We compared efficacy of hemostasis between the initial endoscopic hemostasis group (ENDO group) and the initial angiographic embolization group (EMBO group). The primary outcome was initial hemostasis success rate and the secondary outcomes were delayed bleeding rate, subsequent embolization rate, 28-day mortality, transfusion amount, time to first hemostasis, total hemobilia time, and incidence of hypovolemic shock.

Results

A total of 26 patients with hemobilia were included in this study and 17 patients (65.4%) were identified as the ENDO group and nine patients (34.6%) were classified as the EMBO group. The success rate of initial hemostasis was 88.2% (15/17) in the ENDO group and 100% (9/9) in the EMBO group ( P = 0.529). The rate of delayed bleeding in the ENDO group was 17.6% (3/17) and 0.0% (0/9) in the EMBO group ( P = 0.529). Total hemobilia time was shorter in the ENDO group than in the EMBO group (mean: 281.5 ± 1022.4 minutes vs. 5002.8 ± 7982.6 minutes; P < 0.001) Stent insertion depth was associated with successful hemostasis without delayed bleeding. ( P = 0.015).

Conclusions

Endoscopic hemostasis using SEMS for hemobilia appeared to be a feasible bridge therapy.

TLR2-Bound Cancer-Secreted Hsp70 Induces MerTK-Mediated Immunosuppression and Tumorigenesis in Solid Tumors

Background: A hallmark of cancer is the presence of an immunosuppressive tumor microenvironment (TME). Immunosuppressive M2 macrophages (MΦs) in the TME facilitate escape from immune surveillance and promote tumor growth; therefore, TME-induced immunosuppression is a potent immunotherapeutic approach to treating cancer. Methods: Cancer cell-secreted proteins were detected by using liquid chromatography-mass spectrometry (LC-MS). Neutralizing antibodies (nAbs) were used to assess which proteins were involved in MΦs polarization and differentiation. The protein-protein interaction was characterized using co-immunoprecipitation and immunofluorescence assays. Cancer-secreted heat shock protein 70 (Hsp70) protein was quantified using an enzyme-linked immunosorbent assay (ELISA). MΦ polarization and tumor growth were assessed in vivo with subcutaneous LLC-GFP tumor models and toll-like receptor 2 (TLR2) knockout mice; in vitro assessments were conducted using TLR2 knockout and both LLC-GFP and LN227 lentiviral-mediated knockdown (KD) cells. Results: Cancer cells released a secreted form of Hsp70 that acted on MΦ TLR2 to upregulate Mer receptor tyrosine kinase (MerTK) and induce MΦ M2 polarization. Hsp70 nAbs led to a reduction in CD14 expression by 75% in THP-1 cells in response to Gli36 EMD-CM. In addition, neutralizing TLR2 nAbs resulted in a 30% and 50% reduction in CD14 expression on THP-1 cells in response to MiaPaCa-2 and Gli36 exosome/microparticle-depleted conditioned media (EMD-CMs), respectively. Hsp70, TLR2, and MerTK formed a protein complex. Tumor growth and intra-tumor M2 MΦs were significantly reduced upon cancer cell Hsp70 knockdown and in TLR2 knockout mice. Conclusions: Cancer-secreted Hsp70 interacts with TLR2, upregulates MerTK on MΦs, and induces immunosuppressive MΦ M2 polarization. This previously unreported action of secreted Hsp70 suggests that disrupting the Hsp70-TLR2-MerTK interaction could serve as a promising immunotherapeutic approach to mitigate TME immunosuppression in solid cancers.

Transurethral resection of the prostate across continents: a meta-analysis evaluating quality of gold standard in the twenty-first century

PURPOSE

To compare outcomes of transurethral resection of the prostate (TURP) across different regions worldwide over the past two decades.

METHODS

A systematic review and meta-analysis of randomized clinical trials indexed to PubMed that assessed TURP. A total of 102 studies with 8,454 patients were included and grouped by continents: Europe, Asia, Africa, and Others (North America, South America, and Australia). International Prostate Symptom Score (IPSS), peak flow (Qmax), postvoid residual urine (PVR), PSA levels, prostate volume, and Sexual Health Inventory for Men scores (at 3, 12, and 36 months) were assessed, along with postoperative complications. Heterogeneity across studies was classified as low (I2 < 25%), moderate (I2 = 25-75%), or high (I2 > 75%).

RESULTS

TURP consistently exhibited significant enhancements in IPSS, Qmax, and PVR across various regions. Notably, PVR demonstrated high heterogeneity (I²=100%). TURP presented low complication rates with TURP syndrome (2%), bleeding (8%), and blood transfusion (6%). However, significant heterogeneity was observed, particularly for clot evacuation (I2 = 87%), irritative symptoms (I2 = 96%), and incontinence (I2 = 84%). The retreatment rates at 1 and 3 years were 5% and 7%, respectively, with significant differences across regions.

CONCLUSION

Global outcomes of TURP lack a discernible trend. The substantial heterogeneity observed among continents suggests a lack of standardization. Nevertheless, uniform symptomatic improvements among patients still support TURP as the gold-standard surgical treatment for benign prostatic hyperplasia, despite variations in its results worldwide.

Safety and efficacy of faecal microbiota transplantation in patients with acute uncomplicated diverticulitis: study protocol for a randomised placebo-controlled trial

Background

Little is known about the involvement of gut microbiota in the disease course of diverticulitis and the potential benefits of manipulating the gut milieu. We propose to conduct a randomised placebo-controlled feasibility trial of faecal microbiota transplantation (FMT) given as capsules to patients with acute uncomplicated diverticulitis.

Objectives

The objective is primarily to investigate the feasibility of clinical safety, explore efficacy associated with FMT in this patient population, and examine changes in patient-reported quality of life and the composition and function of the gut microbiota.

Design

Study protocol for a randomised placebo-controlled trial.

Methods and analysis

Participants with acute, uncomplicated diverticulitis, as confirmed by computed tomography (CT) scan, will be recruited from Odense University Hospital (Denmark) and randomly assigned to either the intervention group or the control group. The intervention group will consist of 20 patients who receive encapsulated FMT. The control group will also consist of 20 patients, receiving placebo capsules. Primary safety endpoint: Patient safety is monitored by (a) the number of re-admissions and (b) the number of adverse events within 3 months of FMT/placebo; Primary efficacy endpoint: Reduction in the proportion of patients treated with antibiotics within 3 months following FMT/placebo; Secondary outcome: Change from baseline to 3 months in the GI-QLI questionnaire. Results will be analysed using an intention-to-treat approach. Adverse events or unintended consequences will be reported.

Ethics and discussion

This is the first study to investigate the safety and efficacy of FMT in patients with acute uncomplicated diverticulitis. The project has the potential to broaden the knowledge and literature on the role of the intestinal microbiota in diverticulitis, and we believe it will elevate our understanding of cause and effect.

Trial registration

Informed consent is obtained from all participants. The study is approved by the regional ethics committee (ref. S-20230023) and the Danish Data Protection Agency (ref. 24/2435). The trial was registered on clinicaltrials.gov (NCT06254625) on 10th February 2024.